NHS and Social Care: Impact of Brexit

Lord Prior of Brampton Excerpts

Thursday 21st July 2016 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, this has been a very helpful debate for me. It has been interesting and insightful, and provocative at times, and has also brought to my attention issues that I had not taken on board before.

I thank the noble Baroness, Lady Watkins, for tabling this debate. It has come earlier than I might have liked, because I have not had a chance to think about all the issues raised, but that is no bad thing. Maybe we should have a similar debate in three or four months’ time, once the Government have had more of a chance to react to the Brexit decision. I also thank the noble Baronesses, Lady Watkins and Lady Emerton, for all the work that they do to promote the great cause of British nursing. It is a very important issue and I think that the work they do is appreciated by everyone in the House.

I will make a couple of introductory comments. First, I will just put something on record, which I think everyone in the House will agree with, to recognise the fantastic job that is done by EU nationals and nationals from around the world. The NHS could not survive in its current form without the extraordinary contributions that they make. The second thing is to agree with the words of the noble Lord, Lord Hunt, and other noble Lords in condemning any racist or hate behaviour. It is totally unacceptable, and people who do it should be exposed to the full force of the law. I also say to my noble friend Lord Shinkwin how moved I was by his personal story, which brings home to everyone that nursing and medicine is a noble profession.

There has been a lot of doom and gloom—there have been points in this debate when I felt like slitting my wrists, to be honest with your Lordships. There is of course a lot of uncertainty at the moment, which is a worry to many people, but we should just remind ourselves, as the noble Lord, Lord Crisp, mentioned, that we have some of the finest medical research and life sciences research in the world and punch well above our weight. Just in London, we have UCL, Imperial and King’s. We have Oxford, Cambridge and Manchester—we have some extraordinary research going on. We have some of the finest medical education, and some of the oldest and best medical schools in the world in England, Scotland and Northern Ireland. Many people still regard the NHS as having some of the best standards in the world. The comprehensive nature of our offering to people is still hugely admired around the world. We have some of the most efficient hospitals and the best primary care in the world. Of course there are some serious risks and issues, but let us not forget the extraordinary institution that the NHS is.

I turn to the Motion before us. Healthcare employment is a hugely dynamic area. We are focused today on the implications of Brexit, but the pressures and dynamics that come into play with our healthcare workforce are huge. For example, there is the changing role of technology and the growth of self-care enabled by telemedicine and other apps that we now have. There are demographic changes and the new models of care that are being developed. There is the impact of pay policy, for example the cap on the public sector. There is the huge underlying impact of our economy. There is the need to move more care out of acute or hospital settings. These are all having a big impact on workforce planning.

Brexit is one factor—it is an important factor but by no means the only one. It has a huge impact in two respects. First, in that it has an impact on our economy, it will have a huge impact on how we provide healthcare in this country. Any tax-funded system such as the NHS is going to be hugely impacted by the size of our overall economy, but there is not much point in debating that today—you can argue whether there will be a short-term or long-term impact from Brexit, or whether it is going to be positive in the long run, but these are all issues that will have to be decided in the future. The big impact will be on workforce mobility. For all kinds of historical and current reasons, we have a very high number of people from other countries working in our system, which I will turn to later.

I will start with safe staffing, which was referred to by a number of noble Lords and is a key part of the Motion before us. Responsibility for safe staffing rests with hospital boards: there should not be any one-size-fits-all staffing level. Trusts should have arrangements in place to ensure they have the right numbers and skill mix of staff needed to deliver quality care, patient safety and efficiency, taking into account factors such as acuity and case mix, ward layout and the like.

On 6 July, the National Quality Board published refreshed guidance on safe staffing. It has been drafted with members of the board, which includes NICE and the CQC, and has been independently reviewed and approved by Sir Robert Francis. It is worth noting that when Robert Francis wrote his report on Mid Staffs—I am probably one of the few Members here who have read the entirety of that report—he specifically did not recommend fixed staffing levels. He was very clear about that.

The guidance reminds the NHS that in making decisions about safe staffing, trusts should focus on outcomes rather than inputs and make use of a range of resources and metrics, including the care hours per patient day metric, to measure and deploy staffing resources most effectively. I will quote just a short part of the report because it is important, and because it stresses professional judgment. It states:

“Professional judgement and knowledge are used to inform the skill mix of staff. They are also used at all levels to inform real-time decisions about staffing taken to reflect changes in case mix, acuity/dependency and activity”.

That is important. You cannot rely on just formulae and algorithms—this is true throughout medical care—you have also to rely on professional judgment. When a new patient comes into a ward who may be likely to fall or who suffers from psychosis of one kind or another, you will have to change your staffing mix. There is a danger in laying down staffing ratios: everyone then works to the minimum, gaming starts and you start counting certain people in the mix but not others. The importance of the new advice is that we must rely on the professional judgment of ward sisters and the like.

I turn to the impact of Brexit. Until exit negotiations are concluded, the UK remains a full member of the European Union and all the rights and obligations of EU membership continue to apply. The working time directive and directives on speaking English, to which the noble Viscount, Lord Bridgeman, and others referred, still apply. But when we leave the European Union, depending on the outcome of the negotiations, it will be for us to decide whether we want to keep the working time directive, for example, and whether or not we want to change it to make it more in line with the recommendations of the Royal College of Surgeons. That decision will be ours to take at the time.

The Government’s position is clear. We agree with Simon Stevens that it should not be controversial to provide early reassurance to NHS employees from the EU that they continue to be welcome in this country. This is something we have done already. The Prime Minister has been clear that she wants to secure the status of UK nationals abroad as well as EU nationals already living here. Indeed, in his final PMQs, the previous Prime Minister also made that absolutely clear.

We are about to begin these negotiations and it would be wrong to set out unilateral positions in advance, but be in no doubt: we recognise that all NHS staff from overseas make a huge contribution to our country. We have had lots of figures today and I think you are all sick of them, but currently, there are estimated to be 53,000 workers from EU member states in the NHS and 80,000 in the social care system. The proportion of overseas and EU staff is much higher in some parts of the country, especially London. Great Ormond Street was mentioned as an example. There are some London hospitals, in particular, where there is a very high proportion of EU staff.

It is very important that the staff are not unnecessarily concerned about their future. A message of reassurance to all NHS staff has already been sent by Bruce Keogh and Jeremy Hunt emphasising the vital role played by EU nationals working in our health and social care system. This is as true for non-clinical staff and those working in social care as it is for the 10% of NHS doctors and 4% of nurses who are from the EU. It will be a key priority in our negotiations to seek to ensure that those dedicated staff are able to continue making their outstanding contribution.

We are top of the OECD table in the number of people working in our health and social care system who come from overseas. In part, this is a legacy of empire and the English language and, now, because of our membership of the EU. One in three doctors and one in eight nurses were trained overseas. In a sense, for an employer it is a quick fix to employ a lot of people from overseas; it saves us the cost of training and you can get them straightaway. But I just do not think that it can be desirable that we should depend to that extent on people trained overseas. It did not just apply to those from low-income countries. The noble Lord, Lord Crisp, talked about the WHO commitment that we made to reduce our dependence on those people; it is outrageous to bring people in from low-income countries. It may be different in some parts of the world where they produce deliberately more than they need—in the Philippines, for example. But as a general rule, to import doctors and nurses from low-income countries is ethically completely wrong.

It is a risk that with Brexit we will, in the short term at least, find that there are fewer people from the EU whom we can recruit, but this is a huge opportunity to train our own people—to train more people in this country to be doctors and nurses. This is one of the great humanitarian professions. In 2002, 50% of all new nursing posts were made up from people coming from overseas. It peaked at 50% in 2002 and came progressively down to about 10% in 2008, but since the Mid Staffs report it has climbed again to a point where it is 30%. It strikes me that that is too high, and that we must do more to increase the supply of nurses and doctors, and to retain them, ourselves.

So what have we done to boost the supply of domestically trained staff? We have already increased the number of key professional groups being trained. For example, the number of nurse training places being commissioned each year has increased by 15% since 2013, and we are committed to ensuring 5,000 more doctors working in general practice by 2020. The reforms to the funding of training for nurses and allied health professionals will further boost supply by removing restrictions on the number of training places and will result in 10,000 more nurses being able to enter the workforce by 2020. Health Education England estimates that in total 40,000 more nurses will be available by 2020. I accept that, as the noble Baroness, Lady Watkins, said, there is a risk that removing the bursaries and going to a loans system might deter some nurses—but all the evidence suggests that that is not the case and that, on the contrary, many thousands of young men and women, as well as older men and women, who wish to become nurses, are unable to be trained because of the cap on nursing because of the bursary system. So there is strong evidence to suggest that moving to loans will increase the availability of nurses and AHPs.

Following the Carter review, we are also looking to increase the efficiency with which we use our existing staff and improve productivity, by changing skill mix through the introduction of new roles. This will ensure that highly trained professional staff are properly supported and able to use their skills to do things only they can do. We have talked about the new nursing associate role, and I am very happy to meet the noble Baronesses, Lady Watkins and Lady Emerton, with Health Education England, to discuss that role in more detail, if they would like to do so—perhaps after the summer. If they would like to have a meeting with HEE, I am very happy to arrange that. We are also introducing the role of physician associate, which is a postgraduate qualification; following an undergraduate degree in science, say, there are 90 weeks of training to become a physician associate. That, again, will improve our skill mix.

The Government’s expanded apprenticeship programme will help NHS employers to recruit staff and reduce reliance on expensive agencies. Through the programme, the NHS is developing a clear progression route for healthcare support workers to become qualified healthcare professionals. This will allow trusts to develop their healthcare support workforce and provide individuals an opportunity to earn and learn. We are investing in new technology across the health and social care system to improve productivity for our staff. I give one example only, because time is running out. Most trusts now have new rostering systems, which enables us to ensure that the workforce is spread more evenly across the day, so that we do not have peaks and troughs when in some parts of the day we are understaffed and in others we are overstaffed. There is a lot we can do to improve the productivity of the workforce we already have.

I should turn to social care because it is a hugely important area. We have so often done a disservice to social care. People who work in social care do incredibly important jobs. I am sure other noble Lords have visited nursing homes, care homes and care homes for dementia. People who work in those jobs, often on minimum wage, do an extraordinary job. Somehow working in nursing homes and residential homes does not have the status that it ought to have. It is a vital service for many older and disabled people and provides support to the most vulnerable people in our society. The latest figures estimate that people with EU nationality make up 6% of the 1.3 million adult social care workforce, which is about 80,000 jobs. EU workers are highly represented in regulated professions in this sector—nurses, OTs and social workers—and account for around 9% of those jobs.

Social care is a sector of opportunity with vacancies for the right people. We have to change the status of people who work in social care so that we can attract more people from this country into that profession. What are we doing? The Cavendish review brought in the care certificate, so we are trying to improve the training of people in this area. We are trying to integrate social care much more with healthcare. The Airedale care home vanguard programme is a good example of that. The national living wage is important in rewarding people who work in this important sector, who are often on very low earnings.

I want to conclude more generally. The noble Baroness, Lady Greengross, said that the turnover rate in social care was 24.3%, which is a huge figure. If we do not treat people properly, get them engaged in what they are doing and trust them, we will have high levels of disengagement, absenteeism, sickness and staff turnover. I do not know so much about social care, but I do not think that in the NHS we do a great job in engaging our workforce although of course some hospitals are exceptions to that. For example, the workforce race equality standard shows very high levels of bullying of people from BME backgrounds. Actually, there are very high levels of bullying of people from all backgrounds in the NHS. This is not because I am pro-private sector or anti-public sector or anything like that, but some of our best private sector companies treat their workforce with a far higher degree of trust and dignity and give them much more support and more training opportunities than we sometimes do in the NHS. In terms of retaining the staff we have, having trained them, there is a great deal that we can do. We can do that job much better.

My time is running out so, as summer beckons, we should retire, perhaps with a glass of Cobra Beer, and enjoy it.